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“I Am Not Bound to Win, But I Am Bound to Be True”

So many said it would never happen. But now, on Sunday, March 21, 2010, it appears that reformers have the votes.. Rep. Bart Stupak, the leader of the anti-abortion hold-outs, has announced that he will vote "yes." – (Under the agreement, President Barack Obama will sign an executive order ensuring that no federal funding will go to pay for abortion under the health reform plan This really doesn't change anything. Stupak got nothing except face-time on television.)

At last, Congress is about to take the first step toward transforming what we euphemistically call our health care "system." In the years ahead, the laissez-faire chaos that puts profits ahead of people will be regulated, with an eye to providing affordable, evidence-based, patient-centered care for all.

Since I began writing this blog, I have predicted that Medicare reform would pave the way for health care reform, and this bill makes that possible. Under the legislation, Congress will no longer be in a position to thwart Medicare’s efforts to rein in spending by eliminating waste. Not everyone is happy about this. Over at Politico.com former Republican Senator Bill Frist and former Democratic Senator John Breaux register their protest in a column titled "Keep Medicare in Congress' Hands."

Under reform, politicians and lobbyists will no longer have the power to decide what Medicare pays for and how it pays for it. Frist and Breaux put their finger on a critical change at the very heart of the legislation when they complain that an “Independent Payment Advisory Board,” made up of physicians and health care experts, will be able to propose changes in Medicare payments that “become law unless Congress enacts its own proposal to achieve the same level of cuts.” Legislators will be loathe to take responsibility for cuts. Moreover “Congressional leaders will have to muster . . . .a super-majority of votes if they want to overturn the board’s decisions.”

Medicare and the Public Option

Ultimately, Medicare will help set standards for better, more efficient medical care, and in that role, it could serve as a partial substitute for the public option. When Joe Lieberman decided to kill a government alternative to private insurance, saying “I’m not going to let this happen,” I couldn’t believe that one sanctimonious and spectacularly solipsistic Senator could do that much damage. But he did. The Democrats who followed him were too weak to take a stand on their own, but he gave them a faux leader. That made the difference.

Liberals were horribly disappointed by the loss of the public option. I myself had called it “the heart” of reform. But like many others, I took a deep breath and a long, hard look at what the legislation would still be able to do. At that point, I realized that Medicare, like a public option, could set a high bar for healthcare by insisting on value for our healthcare dollars.

As I explained earlier this month, under the reconciliation bill Medicare will have the power to roll out successful “pilot projects" nationwide—without waiting for Congressional approval. In the past, Medicare has launched many very successful “demonstration projects” that improved quality while cutting costs. But because these were “demonstration projects,” and not “pilot projects,” Medicare could not implement them without going through Congress.

And in Congress, demonstration projects that reined in spending were often unpopular. After all, whenever you save health care dollars, you cut into someone's revenue stream. So, on more than one occasion, Congress has blocked Medicare reforms.

For example, one demonstration project “bundled” payments to doctors and hospitals involved in by-pass surgery at seven hospitals, encouraging doctors and hospitals to collaborate in figuring how to make care more efficient. As a result, Medicare saved millions; both hospitals and doctors actually saw higher profits, and patient satisfaction soared. Yet Congress never let Medicare implement the project on a larger scale.

Under the new legislation politicians and lobbyists will no longer be able to block change. Inevitably, Medicare reforms will ripple out into the private sector. Insurers would be happy to save money. They have made it clear that if Medicare leads the way in reining in health care inflation, they follow.will

Who Would Have Guessed?

This is just one of many provisions in the final legislation that will help rescue our health care system from the lobbyists. This may not be a great bill, but it represents a remarkably good start. As Bob Wachter, Associate Chairman of the Department of Medicine at UCSF, and a leader in the world of patient safety, pointed out yesterday on The Health Care Blog: despite the insanity of the past year—the tea-parties, the lies, and the extraordinary display of self-interest exhibited by some legislators on both sides of the aisle—what has emerged is a surprisingly sane piece of legislation.

“Unmistakably, the mojo has shifted back to the Democrats,” Wachter declares. “It is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.)”

I wholeheartedly agree. Ultimately the Republicans did reformers a gigantic favor by presenting such unwavering opposition to reform. The bi-partisan Summit marked a turning point. At the time, I wondered what President Obama hoped to accomplish. It seemed obvious that the opposition was quite definitely not inclined toward compromise. But the summit dramatized that fact in a way that talking heads and talking points never could.

The president was patient. He listened calmly, while Republicans made it painfully clear that they just weren’t interested in universal coverage. They would be willing to cover 3 million, but not 30 million. Suddenly, all of the other details fell away. Those two numbers stood out in stark contrast to each other. Shall we save three million or thirty million? Not dollars, but human beings.

What is distressing is to realize that the conservatives do represent some part of the public—including many of those protesting in Washington yesterday. Jon Cohn, who was there, reports that to conservatives protesting on the Capitol lawn Saturday, Health care reform is “about having their money taken for the sake of somebody else's security. When they hear stories of people left bankrupt or sick because of uninsurance, they are more likely to see a lack of personal responsibility and virtue than a lack of good fortune. As my colleague Jonathan Chait has observed, theirs is an extreme version of a view common (although surely not universal) on the right: That individuals can fend for themselves, as long as they are responsible and as long as the government gets out of the way.”

At a recent conference where I was doing a Q&A with the audience, a young man asked how I justify asking people to pay for someone else’s health care. My response: “There but for fortune.” He nodded. Somewhat to my surprise, he seemed satisfied with the answer.

Those who oppose universal coverage display a lack of compassion that I find baffling. To be fair, let me add: I’m sure that some conservatives in Congress do care about the suffering that the uninsured endure, but they—or their leaders– cared more about “breaking Obama.” For some, this was never about health care.

The Process was “Nauseating,” but the Policy That Emerged “Ain’t Bad”

Yet despite the rage, despite the ugliness of the political process, the legislation that has emerged “ ain't bad," Wacther observes. "To an impressive degree, the crazy deals, the budget sleights-of-hand, and the extremist positions have been or will be stripped out of the final text. The bill will manage to cover most uninsured Americans. Its new revenue streams are not magical: higher taxes on wealthy Medicare recipients, some take-backs from generously funded Medicare HMOs . . . The most heinous aspects of the under-regulated insurance system – particularly the exclusions for preexisting conditions and the possibility of losing insurance after becoming ill – will become memories of a crueler American past, like slavery and McCarthyism.” Wachter’s analogies are apt. With this legislation, we have declared an end to cruelties that have no place in a civilized society. We have decided, once and for all, that we, as a society, have an obligation to make medical care available to all, and that no one should be punished for being sick.

Over the long term, reform will save money, but the legislation does not pretend that insuring 30 million American won’t cost anything. The bill raises taxes on individuals earning over $200,000 (and couples earning over $250,000
). In the midst of a recession, the middle-class is not in a position to help. But this lucky group–the top 3%– is. Over the past thirty years, those at the top of the income ladder have watched their marginal tax rate fall, while their incomes soared. (One way to measure the gains high-income Americans have made: in 1980, the top 5% earned 2.86 times median income; today they bring home more than 3.5 times median income.) The bill also saves billions by cutting back on windfall payments for insurers who offer Medicare Advantage—another sensible decision.

Keep in mind, even if we had not decided to protect the uninsured, we would have had to raise money to save Medicare from insolvency. Inevitably, we would have had to ask wealthier Americans to contribute more. Under reform, we can save Medicare, and expand coverage while squeezing waste out of the system.

We’re Moving In the Right Direction: Details That Have Been Overlooked

We all acknowledge that the bill is “not perfect.” As Wacther points out, “Not everyone is covered. The problems with the malpractice system remain largely unaddressed. . . Lots of newly insured people won’t be able to find a primary care doc. Care will remain fragmented and chaotic for the foreseeable future.”

This is all true—and is one reason why we’ll need three years before we can make full-scale health care reform a reality.

“But even in these areas,” he argues, “the winds are blowing in the right direction: support for comparative effectiveness research; experiments with bundling, Accountable Care Organizations, and Medical Homes; promotion of improved transitions; malpractice pilot studies; a small dose of steroids for MedPAC,” he adds, referring to the new power given to the Independent Payment Advisory Board. “And maybe, just maybe,” Wacther adds, “a renewed sense that Washington can tackle hard problems.”

During more than a year of debate, the media focused so intently on the political process (who’s winning? who’s losing?), that it often neglected the details of health care policy that make this legislation so important. There are many provisions in the final bill that have received relatively little attention. Did you know, for instance, that Medicare beneficiaries will be able to get preventive care recommended by the U.S. Preventive Services Task Force without paying a co-pay or worrying about a deductible? This provision goes into effect January 1, 2001. Six months after the legislation passes, private insurers also will be required to offer free preventive in any new plans that they offer to the public.

Insurers also will be asked to spend more on medical care, less on administration–or give money back to their customers. Under the legislation, plans in the individual and small group market will be required to spend 80 percent of premium dollars on medical services, and plans in the large group market (where administrative costs are lower) are expected to pay out 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Again, this will go into effective on January 1, 2011. (Thanks to Health Beat readers Walter Ballin, and “run 75441” who inspired me to do a little research by asking questions about these provisions.)

I’m sure that some of you are thinking that letting insurers keep 15 percent to cover administrative costs sounds overly generous. I haven’t done the numbers, but I wonder: could insurers make do with 12%.? What I do know is that today, some insurers spend close to 20% of premiums on advertising, marketing, lobbying, underwriting and salaries. So the new rule should lead to savings. Again, not perfect, but an improvement.

Moreover, the truth is that our insurance system is labor intensive—and paper intensive. We are told that Americans want “choices,” and as a result the insurance industry offers a smorgasbord that involves an enormous amount of paper work. We have many more different insurance plans than most countries (with many more reimbursement forms). And Americans are constantly changing policies, either because they change jobs, or because they are looking for a better deal. All of this shuffling around is expensive.

This is a major reason why the private insurance industry’s administrative costs are so much higher than Medicare’s. Under Medicare there is one package of benefits for everyone, and once a senior enrolls in Medicare, he usually stays put.

As single-payer advocates will tell you, this saves an enormous amount of paper work. Under a single-payer system, you can save even more if all doctors work for the government, all hospitals are owned by the government, and they all are required to charge the same fees—set by the government. But this point in time, most Americans patients and doctors are not ready for such a radical change. I doubt we ever will want to turn physicians into government employees who work for government-owned hospitals. Thus, we will spend more on administration than some other countries.

That said, I do believe that over the next three years, the odds are high that Congress will add a public option to reform legislation.

Today’s vote represent the beginning of a process- and there will be no turning back. Conservatives will rail on about repeal– they'll scream "unconstitutional" until they are hoarse. But this is major legislation, like Social Security or Medicare, and it will not be overturned. It's worth nothing that when Social Security was making its way through Congress, some insisted that it was unconstitutional to think about letting government go into the insurance business. (Thanks to HealthBeat reader Don Levit for pointing this out.) Then, as now, the naysayers had no legal ground for their claims.

Whatever the conservatives may say, the legislation that will pass today is far from extreme. As Wacther notes “The fact that it has no chance of attracting a single Republican vote speaks volumes about cold political calculation, and relatively little about the nature of the changes the bill will usher in. This is, in fact, a bipartisan bill – one that deftly splits the difference between lefties who want single payer and massive government involvement, and righties who want to ‘keep Government out of my Medicare!’

In the end, reformers stayed the course. As Dan Rather reminds us in the interview below, when Lyndon Johnson persuaded Congress to pass Medicare, the country was not nearly as polarized as it is today. I am sorry to see the nation divided, but in this case, I believe that such sharp differences provided clarity. The moral choice was clear—as clear as it was when Congress enacted civil rights legislation. To his great credit, d espite an extraordinarily hostile environment, President Barack Obama persevered, and in the end he stood up. Last night, he quoted Lincoln: “I am not bound to win, but I am bound to be true.” Often, being true to yourself , and to principle, is the only way to win.

29 thoughts on ““I Am Not Bound to Win, But I Am Bound to Be True””

Dear Maggie,
In advance of this historic victory on US health care reform within a few hours I wish to extend my heartfelt gratitude for your playing such an important role through your writing mostly on The HealthBeat Blog and your book Money Driven Medicine
When I first “discovered” you years ago the TPM Blog I have rarely missed any of your writings.
You were/are knowledgeable, prolific, exceedingly responsive to your readers and yet passionate for fighting for what is right.
Personally I do not believe in gloating and I won’t gloat. But tonight I intend to savor and celebrate this important victory for the American people.
My gratitude to you as my favorite Health Care Reform blogger and one who inspired me personally several times to go own when things looked bleak.
I fully recognize and accept the hard work ahead. But tonight I shall dance and think of people like you.
Be Well,
Dr. Rick Lippin
Southampton,Pa

Hi Maggie:
I had not known you long and I just stumbled upon your blog while doing research for writing something for “Angry Bear” (shameless plug . . .). It has been an up hill battle on healthcare, the lack thereof, and the inconsistencies of the arguments against a plan.
It appears we are on the road to a better tomorrow.

Maggie:
I second Rick’s sentiment….kudos to you. You have been a tireless soldier in this cause!
Money Driven Medicine was a compelling and timely addition to the national conversation on health reform.

I third the motion. In addition, Maggie has managed to keep posters civil, a difficult task these days.
Erick Erickson of RedState, of course, is already trying to continue the forcing of the GOP to the ultraright: “Pledge immediate repeal in toto of Obamacare should it pass. No nibbling at the edges — the whole thing and we pledge our lives, fortunes, and honor to crushing any member of Republican leadership who refuses to get on the full repeal bandwagon.”

I also will join the chorus thanking Maggie for her unswerving efforts to advance meaningful reform. Thank you!
Despite the shortcomings of the legislation paired with the severe ideological affront of passing a national law that forces people to purchase a private health insurance policy without providing any choice of a public insurance option, I have continued to support rounding up the “yes votes” in Congress. Maggie has been a leader and a source of inspiration to keep many of us in the reform movement well informed and slogging forward.
There is such a huge amount of important work to do to improve healthcare access, cost, and quality. I’ve known this for decades from my work as a nurse and having ill family members. Many of us have our own horror stories about breakdowns in “the system”, most of which can be traced to the perverse nature of our money-driven medical industrial complex. The current health reform bill has the potential to put us on track to remedy many of the problems (“problems” is a gross understatement!! — we’re in a crisis). This work cannot begin on a national scale soon enough!
The timing of this is so surreal for me; my life has been turned upside down in the past 2 weeks when my sister developed one episode of shortness of breath walking home from the grocery store. She is now in a hospital bed diagnosed with 5 tumors, including one the size of a tennis ball in the lung, 2 in her trachea, and 1 in her brain. Many lymph nodes are affected, as well. She is being incredibly strong and keeping her sense of humor. Her caregivers have been excellent but “the system” has already failed her a number of times during her hospitalization. Thankfully I’m a nurse and together with other family we are checking everything and speaking up quickly when things go awry. Not every patient has this, nor should they have to.
Health reform has always been for people like my sister Laura, who has had health challenges from an early age and has not always had access to timely, quality care. Partly because of these experiences I became involved in advocating for fundamental system reform grounded in the principle of “Health Care for People, Not for Profit” and forming a group to work on achieving this vision. That was back in 1997. The founding “Call To Action” can be read at the below link. It’s a great way to mark today’s vote in Congress to advance health reform.http://massdefendhealthcare.org/about/call-to-action.shtml
Let us continue to work together to stay on course and achieve the reforms we so urgently need for our country and its people. Thank you, Maggie, for helping to lead the way.

Well let me join the chorus too. I was so sure that health reform bill was DEAD after senate lost it’s super majority. Somehow Maggie’s blogs slowly covinced me that this day would come. Everyone agrees that the bill is not perfect.. maybe congress will finally have the guts to improve it. Hope the reconciliation passes.. another nail biter.

Many of you have said it better than I can, but great thanks and congratulations to all who have kept the faith on this issue. Maggie, thank you for your perspective, insight and dedication. Thanks to all who post with insight and civility. I know that today is only one step forward, but I hope and think it is a big one!

Maggie,
I saw your film on PBS and found your blog soon afterward. You were my light through these harrowing and sometimes dark days as the fight for health care reform intensified. I was distraught when the public option was discarded; you helped me see that all was not lost, and so I continued to fight and push for reform. Thank you so much for standing up to offer clarity, perspective, and unwavering honesty.

Maggie,
Well I think it’s a good analysis of what just happened and there are the real benefits you mention. Also, with this “victory” it’s not the time to harp on the negatives of the reform which will declare themselves over time in the implementation phase. However, I do want to take you to task for a couple of remarks about single payer. Paraphrasing, you say that the bill splits the different between lefty single payer advocates who want massive government involvement in health care and….. That’s just not true. The fact is that the current bill inevitably relies upon far more government intervention and regulation than a single payer system such as Canada’s. Single payer programs, like Medicare here or Medicare in Canada are just a uniform disbursement system with a single risk pool. That simplicity is what makes overhead so low. Of course there are some levels of fine tuning, but they fall to the kinds of commissions that the present bill sets up. And all the rules, regulations and curbs on what Wall Street/Insurance and Pharma etc. will and won’t be allowed to do become moot and unnecessary. An entire government watchdog-regulatory apparatus (which I think will be necessary now) can be dispensed with. The main thing is that when you go for the proven (through out the world) fix you create the ability for an independent party (like CMS-Medicare Administration) without a profit ax to grind to negotiate universal rates for all care and services; you create the possibility for global budgeting for hospitals instead of trying to micromanage individual admissions. The government becomes the public obudman of the process and shouldn’t neet to intervene in the care provision processes. Our entire culture fosters the ideal of individual responsibility but that façade, which hides the exploitive nature of money’s dominance of culture and the State, nevertheless results in the need for an authority/bureaucracy to punish those who do not conform. HHS’s mistake of intervening on the service level such as with the DRG (diagnosis related group schedules for hospital reimbursement) hospital payment system led to inappropriate restriction of services–like the Insurance companies do–and thus lots of complaints. That type of bureaucratic intervention should not, and need not be part of a Single Payer system. That’s because Single Payer can control costs externally through global pricing and negotiations and global budgeting that forces the providers of services to figure out how to best allocate their finite funding, whereas this reform will have to go at it through disciplining the market with rules more than through global fixes, leading to unending ongoing conflicts. Any government sponsored financial intervention can and should be limited to being an honest broker through professional-patient advocate boards to set standards, and that is more easily done (not less easily) with Single Payer.
Your other comment that is out of line with my understanding and that of Physicians for a National Health Program leaders is your claim (like the leadership of the Democrats and the President) that neither the public nor the medical community is ready to go all the way to Single Payer. I’ve done public opinion research on this subject myself (see http://www.retropoll.org) and before me and since there have been dozen and dozens of polls on Single Payer that consistently show public support over 60%. The Republicans and their Tea Baggers may be able to make some temporary blips in those poll numbers but the results have been consistent for decades; and now for the first time in 2009 we saw a large reputable poll showing physician support up at 59% for Single Payer reform. As a critic of public opinion research bias I’m willing to say that perhaps all these polls may not be quite as accurate as we want to believe. But there is absolutely no basis to say that the public and doctors are opposed to single payer. That is just placating the noise machine of the Insurance Companies, big Pharma and their Right wing fronts who can bring out a good crowd through fear mongering. There are a few vociferous sectors of physicians (such as the anesthesiologists) who seem quite intransigent on health care reform and who oppose Medicare. But the voice volume of the opposition is not the way we should measure opinion in a democracy. Instead of peripheralizing the opposition because they represent a small proportion of the public, you give them sway when you claim that the public is not ready for Single Payer. That is really unfair. Single Payer is not only the future for health care in the U.S. From a public opinion standpoint it should have been now. That it was put “off the table” had to do with the influence of Wall Street, not to public opinion.
Posted by: Marc Sapir MD, MPH |

Oh my goodness! I have been a supporter of health care reform all along and now that it’s passed I’m not so sure.
I just read a piece in USA Today that says the bill will mean that individuals earning $250,000/year will have to pay $450 more in Medicare payroll taxes. Oh! Those poor, poor people. I’m telling my 24 year old college student son to refuse his extended health coverage, find a $250,000 single earner and send them a check right away.

You have incorrectly described a single payer system. In a single payer system, doctors and hospitals are private – Traditional Medicare is an example of a single payer system – the U.S. government is the sole payer but doctors and hospitals are (mostly) private. In a socialized system (i.e., Beveridge system: England, Spain our own VA system), the facilities are owned by the government and are employees of the government. No wonder so many people are confused about the available options for meaningful health care reform when they are given inaccurate information by people who are suppose to be experts. To repeat: single payer is not socialized medicine because doctors and hospitals are private. Traditional Medicare is single payer; Our VA system is a socialized medicine system (in the way our fire departments and police are socialized protection agencies) because the facilities are owned by the government and health professionals are government employees. If we are ever going to control costs, we must do what every other industrialized country has done – eliminate for-profit health plans playing a central role in financing. In other countries, for-profit health plans provide only supplementary insurance (i.e., private hospital rooms, drugs not covered under the national system, etc.). Where private health plans exist in these other industrialized nations, they are all heavily regulated, NOT-for profit businesses. They must get permission to raise fees and must offer a standard benefit package to prevent cost-shifting. I urge everyone to read T.R. Reid’s book, “The Healing of America” to get an accurate description of the available models of meaningful health care reform. And please, Ms. Mahar, make sure your statements are accurate prior to posting them. You have one opportunity for credibility. When your statements factually incorrect, you lose credibility.

In reply to Christine-
I think you might have a misunderstanding of the semantics around “single payer” (SP). SP is a vague, confusing term, which is why I never liked using it and think it hampers building the requisite social movement for meaningful reform. I prefer to say “Improved Medicare-for-all” or “Streamlined financing with universal coverage”. I usually add “this is also called SP by some”.
Maggie knows that PNHP and many other activists mean improved medicare for all when they say SP, but another form of SP can be a socialized healthcare system and that’s what Maggie was referring to the way I read her post. There are more cost savings to be had with a socialized system, as the OECD data clearly demonstrate.
Of course Maggie will respond directly to Christine, if she chooses, but I wanted to chime in with my perspective, too. We need to hang together as much as possible. Heaven knows there are more than enough negative forces out there trying to stop meaningful reform. Let’s not add to them while we have thoughtful discussion about how to make whatever reform passes get better and better.

Also to Christine:
In the UK, primary care doctors are mostly self-employed and run their own practices under contract to the National Health Service (NHS). Also, there is a thriving private sector alongside the NHS, and NHS consultants are free to work in private practice once they fulfil their weekly NHS commitments, while others work solely in private practice.
Also, some private health insurance companies are for-profit, in the UK and in other countries in Europe.

A Woman’s Place is in the House:
First, let me join others in thanking Maggie for the work she has put in for many years, and for maintaining a forum where civil exchange based on ideas is the norm — somewhat unusual, to say the least.
But I also want to throw some love publicly at Nancy Pelosi. Some of the better informed “now it can be told” analysts now are crediting Speaker Pelosi for providing the push — over the objections of some of his people and his own first instinct — to get President Obama to not only not back a weaker approach than universal care after the MA senate debacle but to double down on the issue by finally throwing the full weight of his presidency behind the passage of the bill. In addition, Pelosi proved to be an absolute master of figuring out just exactly how to get the votes she needed.
Pelosi has demonstrated two things: she is one of the most adept Speakers in history and the best since Sam (Civil Rights, Voting Rights, Medicare, Medicaid, War on Poverty) Rayburn. She also once again showed people like Rahm Emmanuel — she has a history of eating his lunch on a regular basis — that you mess with an Italian grandma at your peril.
So although Obama gets tremendous credit and will be remembered in history as the president who finally made health care a right for all Americans, I hope that Pelosi’s husband served her strawberries and champagne in bed this morning.
Of course Maggie has shown that Irish almost grandma’s swing a pretty big stick too.

You quote Bob Wachter stating that this is a bill “that deftly splits the difference between lefties who want single payer and massive government involvement, and righties who want to ‘keep Government out of my Medicare!’” I think that quote demonstrates why compromise is such a bad thing to do with these people. You can’t discuss policy with people who don’t acknowledge reality.

“Under the new legislation politicians and lobbyists will no longer be able to block change. ”
This lack of review, especially judicial review, may form the basis of yet another challenge – lack of due process. Even the IRS has oversight.
This Bill will become a jobs program for Constitutional Lawyers.

Pat S, Christine, Anne, Marc . . . will be back to respond to everyone . . .
Pat S. Thanks for the kind words.
I share your feelings about Pelosi. Incredible energy, intelligence and courage. I found her inspiring. And I agree, best Speaker since Rayburn.
Who knew?
Not only is she an Italian grandmother, she’s a politician’s daughter, she understands how to count votes, how to get votes. . .
Delighted to hear that she has been eating Rahm’s lunch.
Christine– As Anne points out, I was talking about socialized medicine.
As Anne also notes, single payer is often used loosely–too loosely.
Not sure why you’re so testy– perhpas you’re a disappointed single-payer advocate.
Anne– Thanks! I agree–solidarity.
Marc– All true.

I think it’s a great day for America. We can begin working on the problem of improving health care, and no longer will Americans cower in fear over losing their jobs because it also means the loss of health care.

Hi Maggie,
Like many other readers of this blog, I have appreciated reading your entries over the last year or two. Like you, I applaud the passage of the health care reform legislation, though it is far from perfect.
I wonder, however, about your repeated reassurance that where Medicare goes, the private insurance industry will gladly follow. Your logic was that they want to save money. But how will they be able to do this in light of your previous explanation that many dominant providers in individual markets have more power than the insurance companies? If these providers hold out, the insurance companies will not be able to follow Medicare, right? And then there is the problem of markets dominated by one insurance company. In such a place, the company has no strong incentive to negotiate with providers, and even if it extracts reimbursement cuts, the savings will go only to the consumers, given the 20% limit, so no gain to the officers or shareholders. Until a public option is offered, where are the non-Medicare savings? I would love to read your thoughts.
Thanks.
Richard K. MD

Hi Maggie,
I am no constitutional scholar, but Frist and Breaux’s suggestion that the Advisory Board provision is unconstitutional, based on a comparison with the failed Line Item Veto, sounds ridiculous. The latter was declared unconstitutional because it contradicted the basic constitutional rule on how a bill becomes a law (even though it was a great idea, and the only thing the Confederate States of America got right).
The health reform bill will have been made into law according to the constitution. The rest is regulation, appropriate to the executive.

Dr. Rick, run 75441, Gregg, Chris, Ann,, Chris, Ray, Louis, Jean, Mike
Dr. Rick–
Thank you so much. You were one of my first readers, and I have greatly appreciated your comments and support over the past 2 1/2 years.
You also have been a tireless, persuasive and very intelligent voice for hcr throughout this time (and before.)
You are the ultimate networker.(And I mean that in the best sense of the world. Often “networking” is just social climbing or career climbing– you use it to advance the public good.)
I thank you for introducing me to people who, without you, would never have known that I, or HealthBeat, existed.
Finally, I know that you have met some stone cold opposition to your efforts to advance reform. I remember a phone conversation that we had. I have run into the same opposition.
But ultimately,You–and the country–won!
Run 75441–
I’m so very glad you did stumble upon the blog. YOur comments-and cross-postings–are much appreciated.
Gregg–
Thsnks you so much. Reflective readers like you make the blog what it is. Please keep commenting.
Chris–
I recall e-mailing you more than once for wise advice on how to keep the conversation civil.
The Republican reaction is
interesting. It seems so way over the top. . .
But I suspect that Republicans understand just how powerful this bill will be,.
Conservatives know much more about Big Money than most liberals. They know where it is, how it grows–and the effect this bill will have on our industrial-medical complex, a monster that threatens to eat GDP if we don’t slow down its growth.
I am heartened by their distress.
Ann– You are a medical professional and you live in Massachusetts.
So you know well all of the potential pitfalls of reform.
You also were a single-payer advocate,and I understand how difficult it was to accept a compromise.
This was especially true after Joe L. killed the public option.
But liberals like you made reform possible. If the most liberal Democrats had refused to accept anything short of single-payer, we wouldn’t have health care reform today.
And I truly believe we would have had to wait another 10 years before having a shot at it again.
Your understanding of politics– and the need for both solidarity and compromise—is impressive.
I also believe that we will add a public option to the legislation sometime before 2014.
If it weren’t for people like you, that also wouldn’t be possible.
Chris– Re my description of Lieberman, thank you. I knew him, year ago, in Connecticut, so that inspired me.
Ray–
Reconciliation will be okay– I’m 99% sure. At this point, Obama and Pelosi are in control. The conservatives are just sputtering, throwing temper tantrums because they didn’t get their way. . .They are not good losers.
I’ve very glad that my optimism encouraged you. Frankly, that was my goal: to help people keep the faith.
I couldn’t know ,for sure, if I was right. But I did think that the most constructive thing I could do was to explain why health care reform made sense . . . And I didn’t care if I would be embarrassed by being wrong.
As a blogger, I think my job is to inform and to encourage and explain good ideas, not to call horses. I’m not Jimmy the Greek.
Louis– Yes, today is just one step forward, but it is a big one. As Obama said “Not radical, but major” legislation.
Jean– Such a very kind comment. I truly appreciate it.
I am very glad that I helped some people keep the faith. This is why I write the blog–and respond to my reader’s comments.
Mike–
Indeed, those folks really can’t afford th $450!

Let me add my appreciation, Maggie, for your unfailingly well-informed and thoughtful perspectives on healthcare reform over the past months during which I’ve followed this blog. I’ve cited you often as a bastion of common sense in my frequent efforts to persuade some of my liberal friends that in the proposed legislation, we were witnessing a major, indeed transformative advance in American society, and that the legislation’s many imperfections did not detract from that conclusion, nor should they have weakened our enthusiasm to move forward.
Thanks.